Reproduced From: India
Legal Magazine, August 26, 2019, p.38-39, Available at: http://www.indialegallive.com/e-magazine
By Dr KK Aggarwal
The Prime Minister’s
Ayushman Bharat Scheme is riddled with dishonest practices by hospitals and
common service centres, leading to their de-empanelment and FIRs being lodged
Trust Indians to find
innovative ways to beat any system. The National Health Authority (NHA), the
nodal agency for the government’s health insurance scheme, has found that
hospitals and common service centres (CSCs) have found ways to beat the
centrally-sponsored Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)
system.
Over 250 hospitals out
of 15,955 (7,992 private and 7,963 public) have been de-empanelled for
fraudulent practices and FIRs registered against CSCs for fudging beneficiary
data. In Agra district, 900 CSCs and in Pilibhit district three CSCs were
deactivated and FIRs lodged against the CSC in-charge.
Though this scheme was
introduced for the benefit of all and as many as 30 lakh people have availed of
it, fraudulent practices are giving it a bad name. The fraud being perpetrated
is seeing many forms:
·
A single
doctor conducting surgeries in four districts on the same day (ghost charges).
·
Patients
being charged for expensive procedures not conducted on them.
·
Multiple
surgeries conducted on a single day late in the night.
·
Hysterectomies
on men.
·
Fake
beneficiaries issued cards by CSCs.
·
Ineligible
persons colluding with CSCs (authorised to identify beneficiaries under the
Ayushman Bharat scheme) to deprive real beneficiaries.
·
Unnecessary
expensive procedures being conducted on patients who did not require them so
that the hospital can tap into higher packages’ reimbursement.
·
Ghost
patients being referred to private hospitals by government doctors. The money
meant for the treatment of these non-existent patients is then pocketed by the
government doctors.
·
Nexus
between staff in government and private hospitals. Patients who visit the
government’s primary health centres need a referral slip when they are sent to
a private hospital. The staff has been charging bribes to issue these slips.
The AB-PMJAY system
automatically detected a sudden spurt in similar procedures in a single day in
the same hospital. The Insurance Regulatory and Development Authority of India
and NHA have formed a working group on PMJAY. The group, to be chaired by
Dinesh Arora, Deputy CEO, NHA, will have ten members from both the
organisations. In six months, it will submit a report on how to detect and
deter fraud through a common repository.
The nobility of the
medical profession requires zero tolerance for corruption. MCI ethics
regulation 7.7 clearly says that the name of a person can be deleted from the
register and his licence to practise cancelled permanently in such cases. It
says: “Registered medical practitioners are in certain cases bound by law to
give, or may from time to time be called upon or requested to give
certificates, notification, reports and other documents of similar character
signed by them in their professional capacity for subsequent use in the courts
or for administrative purposes, etc. Such documents, among others, include the
ones given in Appendix-4. Any registered practitioner who is shown to have
signed or given under his name and authority any such certificate, notification,
report or document of a similar character which is untrue, misleading or
improper, is liable to have his name deleted from the Register.”
Regulation 1.7 also
talks about exposure of unethical conduct: “A physician should expose, without
fear or favour, incompetent or corrupt, dishonest or unethical conduct on the
part of members of the profession.” Regulation 6.4 clarifies commissions in
such situations: “6.4.1 A physician shall not give, solicit, or receive nor
shall he offer to give, solicit or receive, any gift, gratuity, commission or
bonus in consideration of or return for the referring, recommending or
procuring of any patient for medical, surgical or other treatment. A physician
shall not directly or indirectly, participate in or be a party to act of
division, transference, assignment, subordination, rebating, splitting or
refunding of any fee for medical, surgical or other treatment.”
Provision 6.4.2 says
that provisions of 6.4.1 shall apply with equal force to the referring,
recommending or procuring by a physician or any person, specimen or material
for diagnostic purposes or other study/work.
Fraud can be of two
types—Intentional (Fraud) and Un-intentional (abuse), according to the American
Medical Association Ethics. These are manifested in many ways, especially in
the coding of bills. For example:
·
When
there is a single billing code available that captures payment for the
component parts of a procedure that should be used instead of unbundling them.
This refers to using multiple billing codes for those parts of the procedure,
either due to misunderstanding or in an effort to increase payment. This can
include charging for hysterectomy, oophorectomy (surgical removal of the
ovaries) and vaginal repair separately when pan-hysterectomy billing is
available.
·
Charging
as new a reused or disposable device.
·
Charging
for high-priced antibiotics which were not used.
·
Upcoding:
Charging for a major time intervention when there was only a minor time one.
For example, the doctor may have met a patient for a few minutes about a
routine question but the coder bills for a full examination lasting 45 minutes.
·
Charging
for two procedures on the same day—e.g., you bill for a lesion excision and
skin repair on a single date. Most simple repairs are included in the
excision billing code, so separately coding the repair would be wrong. But if
the repair was performed on a different site from where the lesion was removed,
it is ok to bill for both and append a modifier to let the payer know the
procedure was separate from the excision.
·
One must
include proper documentation to explain why the procedure requires more work
and investigations. For example, if you excise a lesion on the crease of the
neck of a very obese patient, one must explain that obesity makes the excision
more difficult.
·
Good
documentation of the start and stop times are essential for medical coders to
properly bill for these services.
·
Charging
for multiple sessions of injections. One must report one billing code for the
entire session during which the injections take place instead of multiple units
of a code. For example, if continuous intravenous hydration is given from 11 pm
to 2 am, two administrations will be abuse of billing.
·
Reporting
unlisted codes without documentation. If you must use an unlisted code to
properly bill for a service, you must properly document it.
Honesty is the best
policy and if that is not understood by medical providers, punishment is a
natural consequence.
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of
Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of
India
Past National President
IMA
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